Nokea
A new mother expresses concern about her baby's frequent hiccups. What should the nurse explain about newborn hiccups?
- A. Hiccups are a sign of respiratory distress in newborns.
- B. Hiccups indicate the baby is overeating.
- C. Hiccups are common and usually harmless in newborns.
- D. Hiccups are caused by a lack of burping.
Correct Answer: C
Rationale: Newborn hiccups are common and usually harmless. They are typically caused by the baby's immature diaphragm and tend to resolve on their own. It is essential for parents to understand that hiccups in newborns are a normal phenomenon and do not necessarily indicate any underlying health issue. Choice A is incorrect because hiccups are not a sign of respiratory distress in newborns. Choice B is incorrect as hiccups do not indicate the baby is overeating. Choice D is also incorrect as hiccups are not solely caused by a lack of burping.
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What assessment finding places a newborn at risk for developing physiologic jaundice?
- A. Cephalohematoma
- B. Mongolian spots
- C. Telangiectatic nevi
- D. Molding
Correct Answer: A
Rationale: The correct answer is A, Cephalohematoma. Physiologic jaundice in newborns can occur due to the breakdown of excess red blood cells. A cephalohematoma, a collection of blood caused by ruptured blood vessels between a cranial bone's surface and periosteal membrane, can lead to increased red blood cell breakdown. This increased breakdown can contribute to the development of physiologic jaundice in newborns. Choices B, Mongolian spots, and C, Telangiectatic nevi, are both benign skin conditions and are not directly associated with increased red blood cell breakdown. Choice D, Molding, refers to the shaping of the fetal head during passage through the birth canal and is not related to the development of physiologic jaundice.
The client is being taught about perineal care postpartum. Which instruction should the client receive?
- A. Use ice packs to reduce swelling for the first 24 hours.
- B. Apply heat packs immediately after birth to reduce pain.
- C. Avoid using a peri-bottle to cleanse the perineum.
- D. Use tampons to absorb lochia discharge.
Correct Answer: A
Rationale: The correct instruction for the client postpartum is to use ice packs to reduce swelling for the first 24 hours. This helps alleviate discomfort and promote healing. Applying heat packs immediately after birth is not recommended as they can increase swelling. A peri-bottle is advised for cleansing the perineum, not to be avoided. Tampons should not be used to absorb lochia discharge as they can increase the risk of infection. Therefore, the use of ice packs is the most appropriate and beneficial instruction for perineal care postpartum.
Which of the following interventions is NOT appropriate for a hospitalized adolescent?
- A. Allow the adolescent to assist with procedures when possible.
- B. Encourage them to discuss their thoughts and feelings about the hospitalization.
- C. Encourage them to remain in the room throughout the hospitalization to ensure adequate rest periods.
- D. Encourage peer visitation.
Correct Answer: C
Rationale: Encouraging the adolescent to remain in the room throughout the hospitalization may lead to social isolation, hinder the adolescent's emotional well-being, and impede their recovery. It is essential for adolescents to have social interaction, engage in meaningful conversations, and receive support from peers to cope with the stress of hospitalization. Choices A, B, and D are appropriate interventions as they promote involvement in care, emotional expression, and social support, which are beneficial for the adolescent's overall well-being during hospitalization.
A postpartum client who delivered a healthy newborn is being assessed by a nurse. Which finding would indicate a complication during the early postpartum period?
- A. Moderate lochia rubra
- B. Bradycardia
- C. Elevated blood pressure
- D. Uterine contraction
Correct Answer: C
Rationale: An elevated blood pressure in the postpartum period may indicate the onset of preeclampsia, a serious complication that requires immediate medical attention. Preeclampsia is characterized by high blood pressure, protein in the urine, and sometimes swelling in the hands and face. If left untreated, preeclampsia can lead to serious complications for both the mother and the baby. Therefore, it is crucial for healthcare providers to closely monitor blood pressure levels in postpartum clients to promptly address any signs of preeclampsia. Choices A, B, and D are not indicative of a complication during the early postpartum period. Moderate lochia rubra is a normal finding as it indicates the normal discharge of blood and tissue from the uterus after childbirth. Bradycardia, a slow heart rate, is not typically a concern in the absence of other symptoms or signs of distress. Uterine contractions are essential for involution and are expected in the postpartum period.
A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long?
- A. 2 months
- B. 2 weeks
- C. 1 year
- D. 4 months
Correct Answer: D
Rationale: Transient strabismus, causing the baby to look cross-eyed, is due to poor neuromuscular control of the eye muscles. This condition typically resolves on its own within 3 to 4 months as the infant's neuromuscular control improves. Parents should be reassured that this is a common and temporary issue in infants. Choice A is incorrect as it is too long for the resolution of transient strabismus. Choice B is incorrect as 2 weeks is too short for resolution. Choice C is incorrect as 1 year is too long for transient strabismus to resolve.